In patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), 12-month dual antiplatelet therapy (DAPT) has long been the standard of care. However, emerging evidence suggests that discontinuing aspirin early while maintaining P2Y12 inhibitor monotherapy may reduce bleeding without compromising ischemic protection. We performed a systematic review and meta-analysis to evaluate the impact of early aspirin discontinuation compared with standard 12-month DAPT on clinical outcomes after PCI for ACS. A meta-analysis was performed including randomized clinical trials and post-hoc analyses of randomized trials comparing early aspirin discontinuation (within 1 to 3 months post-PCI) to standard 12-month DAPT in ACS populations. The major endpoints were a composite of net adverse clinical events (NACE), major adverse cardiovascular events (MACE), all cause and cardiovascular mortality, MI, stroke, stent thrombosis (ST), target vessel revascularization (TVR), and bleeding. A random-effects model was used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was assessed using I² statistics. Nine studies were included, encompassing 31,505 patients (15,700 early discontinuation; 15,805 standard DAPT). Across the 9 included studies, early aspirin discontinuation was associated with a significant reduction in NACE compared with standard DAPT (OR 0.77, 95% CI 0.65 to 0.91; p = 0.002) due to reduction in BARC ≥2 bleeding [0.41; 0.32 to 0.52; p <0.00001]. Early aspirin discontinuation, compared to 12-month DAPT resulted in similar risk of MACE [0.88; 0.73 to 1.07; p = .19], all-cause mortality [0.84; 0.69 to 1.03; p = 0.09], cardiovascular mortality [1.02; 0.74 to 1.41; p = 0.92], MI [0.98; 0.77 to 1.25; p = 0.87], stroke [0.97; 0.73 to 1.29; p = 0.82], ST [1.29; 0.83 to 2.0; p = 0.26] and TVR [1.00; 0.79 to 1.27; p = 1.00]. In ACS patients treated with PCI, early discontinuation of aspirin while maintaining P2Y12 inhibitor monotherapy appears to reduce adverse clinical events compared with standard 12-month DAPT. These findings show net benefit of following early aspirin discontinuation strategy due to reduction in major bleeding events without jeopardizing ischemic outcomes.

We present the case of a 46-year-old man with bilateral renal artery stenosis and a previous stent placed on the left renal artery who presented with a hypertensive emergency with flash pulmonary edema and acute-on-chronic renal failure. A renal angiogram revealed extensive thrombosis and in-stent restenosis, which were treated with thrombectomy, angioplasty, and stenting. Our case highlights the importance of careful patient selection for renal artery stenting and close monitoring post-stenting due to the risk of serious complications.

Coronary computed tomography angiography (CCTA) is recommended for the diagnosis of initial coronary artery disease (CAD) in patients with stable chest pain. We sought to understand the prevalence and severity of coronary stenosis observed via CCTA and to determine how integrating these anatomical findings with conventional 10-year atherosclerotic cardiovascular disease (ASCVD) scores could enhance risk stratification and guide clinical decisions. This was an open-label, prospective, single-center observational study including 1,492 outpatients with stable chest pain who underwent CCTA. We collected data on ASCVD risk factors and followed up patients for 5 years to monitor for major adverse cardiovascular events (MACE). We analyzed the prevalence of obstructive CAD (OCAD, ≥50% stenosis) across different ASCVD risk categories and its relationship with MACE. Among 1,492 patients, CCTA revealed OCAD in 16.0%. Over a 5-year follow-up, 7.2% of patients experienced MACE. The presence of OCAD significantly improved MACE prediction beyond ASCVD scores alone. Notably, patients with ASCVD < 7.5% and OCAD had a significantly higher MACE risk (adjusted hazards ratio: 3.634; p = 0.023) compared with those without OCAD. The highest risk was found in the ASCVD ≥ 7.5% with OCAD group (adjusted hazards ratio: 5.101; p<0.001). CCTA provides significant incremental value for risk stratification in outpatients with stable chest pain. It helps uncover a high-risk group that might be underestimated by conventional ASCVD scores, supporting CCTA integration into clinical workups for earlier intervention and improved patient outcomes.

Iatrogenic ST elevation myocardial infarction (STEMI) after aortic valve surgery is a rare complication. Myocardial infarction (MI) due to mediastinal drain tube compression on the native coronary artery is also seen rarely. We present a case of ST elevation inferior myocardial infarction due to post-surgical drain tube placed after aortic valve replacement compressing on the right-sided posterior descending artery (rPDA). A 75-year-old female presented with exertional chest pain and was found to have severe aortic stenosis (AS). After a normal coronary angiogram and proper risk stratification, the patient underwent surgical aortic valve replacement (SAVR). One day after surgery in the post-operative area, the patient was complaining about central chest pain suggestive of anginal pain. Electrocardiogram (ECG) revealed that she has ST elevation myocardial infarction in the inferior wall. Immediately, she was taken to the cardiac catheterization laboratory, which revealed that she has occlusion of the posterior descending artery due to compression by a post-operative mediastinal chest tube. All features of myocardial infarction resolved after simple manipulation of the drain tube. The compression of the epicardial coronary artery after aortic valve surgery is very unusual. There are a few cases of other coronary artery compression due to mediastinal chest tube, but posterior descending artery compression causing ST elevation inferior myocardial compression is unique. Though rare, we need to be vigilant about mediastinal chest tube compression, which can cause ST elevation myocardial infarction after cardiac surgery.

In-stent restenosis (ISR) remains a significant mode of stent failure following PCI. The optimal treatment strategy, however, remains undefined and the role of drug-eluting balloons (DEB) in the management of ISR is also unclear.A meta-analysis was performed to compare the efficacy of DEB in the treatment of ISR against second generation drug eluting stents (DES).Seven studies comprised of 1,065 patients were included for analysis. The follow-up period ranged from 12-25 months. The use of DEB was associated with an inferior acute gain in minimal luminal diameter (MLD) (0.36, 95% CI: 0.16-0.57 mm), higher late loss in MLD (0.11, 0.02-0.19 mm) and a higher binary restenosis rate at follow-up (risk ratio: 2.24, 1.49-3.37). No significant differences were noted in the overall incidence of the analysed clinical parameters between the two groups. When only the randomised controlled trials (RCT) were considered however, there was a strong trend towards higher target lesion revascularisation (TLR; 9.9% vs. 3.6%; RR: 2.5, p=0.07) and a significantly higher major adverse cardiovascular event (MACE) rate (15.7% vs. 8.8%; RR 1.78; p=0.02) with DEB.While equipoise has been demonstrated in selected clinical outcomes between DEB and second generation DES in the treatment of ISR, the suboptimal angiographic outcome at follow-up and the higher TLR and MACE rates associated with DEB observed in the RCT are concerning. The results of the present analysis should be regarded as preliminary, although the generalised adoption of DEB in the treatment of ISR currently cannot be recommended.

Invasive treatment with coronary angiography is preferred approach for patients with non-ST elevation acute coronary syndrome (NSTE-ACS) compared to medical therapy alone. The results from the randomized clinical trials (RCT) that compared the invasive treatment strategy vs. conservative approach in the elderly (≥75 years) with NSTE-ACS has been inconsistent. To compare invasive and conservative strategies in the elderly (>75 years) with NSTE-ACS. We searched PubMed, Cochrane CENTRAL Register and ClinicalTrials.gov (inception through July 10, 2021) for RCTs comparing invasive and conservative strategies in the elderly with NSTE-ACS. We used random-effects model to calculate risk ratio (RR) with 95% confidence interval(CI). A total of 6 RCT including 2,323 patients were included in the meta-analysis. The median follow-up duration was 13.5 months. When invasive approach was compared to conservative strategy, it showed no difference in all-cause mortality in patients aged ≥75 years with NSTE-ACS (RR of 0.85; 95% CI 0.70–1.04; P = 0.12; I2 = 0%). There was significant reduction in MI (RR 0.59; 95% CI 0.49 0.71; P < 0.001; I2 = 0%) and unplanned revascularization (RR 0.30, 95% CI 0.17-0.53, P <0.001, I2 = 0%). Invasive strategy was associated with higher risk of major bleeding when compared to conservative treatment (RR 2.12, 95% CI 1.21-3.74, P = 0.009, I2 = 0%). Comparison of both strategies showed no significant difference in stroke (RR 0.75; 95% CI 0.38-1.46, P = 0.40; I2 = 0%). This updated meta-analysis suggests that in elderly patients (>75 years) with NSTE-ACS, a routine invasive strategy is associated with a reduction in MI and revascularization, while increasing the risk of major bleeding, but without difference in all-cause mortality and stroke.

Introduction: Women are frequently present with questionable angina . Lack of specificity and sensitivity in imaging procedures and absence of a blood-based biomarker that can detect myocardial ischemia earlier than cell death, may contribute to women being under-investigated and under-treated, with worse outcomes. The blood-based biomarkers, Nourin protein and its regulatory miRNAs (miR-137 and miR-106b) are elevated in the setting of myocardial ischemia before it progresses to infarction . Hypothesis: Unlike hs-TnI, Nourin-dependent miR-137 and miR-106b can identify or exclude myocardial ischemia in patients suspected of having CAD, as proven by stress test results. Methods: Serum levels of Nourin miRNAs (qPCR) and plasma hs-TnI were measured blindly in: 1) chest pain patients suspected of having CAD (n=12) both before stress ECHO/ECG test (pre-test) and 30 minutes after test completion (post-test); 2) STEMI patients (n=16); and 3) healthy subjects (n=16). Results: 1) very low baseline levels of Nourin miRNAs in healthy (range: 1.38 to 1.43) and CAD negative (range: 1.84 to 4.53); 2) significant upregulation of miR-137 (2,156 pre and 2,574 post) and miR-106b (423 pre and 521 post) in CAD positive (n=5) compared to CAD negative (n=7) (range: 1.84 to 4.53) pre-test (continuous release in response to chronic myocardial ischemia) and post-test; 3) higher levels in STEMI (4,509 (miR-137) and 950 (miR-106b) pre) compared to CAD (2,156 and 423 pre); 4) over 86% sensitivity and 100% specificity that can “rule out” myocardial ischemia, just as NT-proBNP for heart failure and D-dimer for deep vein thrombosis; and 5) hs-TnI was elevated only in STEMI, but not in CAD patients, pre & post. Conclusions: Assessment of Nourin miRNAs enables the identification of a population of patients with ischemia, but without injury or infarction , and exclusion of myocardial ischemia, based on its strong negative predictive value, thus potentially improving the treatment algorithms for women .

Because left main (LM) coronary artery stenosis is known to have higher mortality and morbidity compared to lesions in other territories, an early diagnosis and management are crucial to prevent worse outcomes. Due to limitations of coronary angiography (CA), the diagnosis of ostial LM stenosis solely based on CA may result in underdiagnosis of such lesions. Therefore, additional testing is often needed either by pressure wire or intravascular ultrasound (IVUS) to make appropriate diagnosis. We, hereby, present a case of left main ostial stenosis in a 56-year-old male that was missed on multiple coronary angiograms, and highlights many of the considerations in the diagnosis of LM disease.

The CardioMEMS™ HF system (Abbott, Chicago, IL), a wireless pulmonary artery (PA) pressure sensor, was approved by the FDA after demonstration of reduction of heart failure hospitalization in New York Heart Association class III patients. These devices are implanted into the desired PA branch via either common femoral or jugular vein access. However, in some patients who cannot undergo the procedure via these routine access sites for various reasons, alternative access is needed. We describe, to our knowledge, the first case of successful CardioMEMS™ implantation via brachial vein access.

Background: Several randomized clinical trials (RCTs) have compared the use of dual therapy (DT), or one of the non-vitamin K antagonist oral anticoagulants (NOAC) with a P2Y12 agent, versus triple therapy (TT), consisting of a vitamin-K antagonist (VKA) along with dual antiplatelet therapy, in patients with concomitant atrial fibrillation after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS). We performed a meta analysis and systematic review of RCTs to evaluate the safety and efficacy of NOAC-based DT in such patients. Methods: The major efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of mortality, myocardial infarction, stroke, stent thrombosis (ST), and urgent revascularization. The International Society on Thrombosis and Hemostasis (ISTH) major or clinically relevant non-major bleeding (CRNM) was the major primary safety outcome. Results: A total of 4 RCTs were included in the meta-analysis with 7942 total patients for analysis (DT: 4377 & TT: 3565). Compared to TT, DT resulted in similar risk of MACCE (OR: 1.12; 95% CI: 0.94-1.34; P = 0.20) and other efficacy endpoints with a trend in increased risk of ST in the DT group (1.55; 0.99-2.44; P = 0.06). DT resulted in lower risk of ISTH major or CRNM bleeding (0.56; 0.41-0.76; P < 0.01), and all other bleeding outcomes except for a trend of reduced risk of TIMI minor bleeding. Conclusion: In conclusion, patients with atrial fibrillation who undergo PCI or develop ACS, NOAC-based dual therapy reduces bleeding outcomes without significantly increasing ischemic outcomes. Future trials should explore the possible differences in stent thrombosis. (C) 2020 Elsevier Inc. All rights reserved.

Isolated external iliac vein compression syndrome is an uncommon cause of nonthrombotic venous stenosis that causes chronic venous hypertension leading to painful swelling, skin discoloration, and ulcer formation. We present a case of an 86-year old man with refractory lower extremity edema for several years who had been treated with diuretics and antibiotics without relief of symptoms. With the help of invasive and noninvasive imaging modalities, we were able to diagnose and manage isolated nonthrombotic left external iliac vein stenosis as a result of ipsilateral external iliac artery compression.

Introduction: Sympathetic renal denervation (RD) can potentially reduce blood pressure (BP) in people with resistant hypertension (RH) and uncontrolled hypertension (UH). While a large sham-controlled trial (SCT) showed similar outcomes of RD vs. sham control, in the recent trials, RD was effective in reducing BP in hypertensive people. We performed a meta-analysis of SCTs of RD vs. sham in hypertensive patients. Methods: Multiple electronic databases were searched since inception through September 2018 for SCTs that compared RD vs. sham. Change in 24-hour, daytime and nighttime ambulatory and office BP were efficacy outcomes. Various adverse events were safety outcomes. Results: A total of 7 SCTs were included in the analysis. RD vs. sham significantly reduced 24-hour ambulatory SBP by 3.45 mmHg [95% CI (-5.01, -1.88); P < 0.0001] and DBP by 1.87 mmHg [(-3.59, -0.15); P = 0.01], office DBP by 2.97 mmHg [(-4.76, -1.18); P = 0.001] and daytime ambulatory SBP by 4.03 mmHg [(-6.37, -1.68); P= 0.0008] and DBP by 1.53mmHg [(-2.69,-0.37); P= 0.01]. RD vs. sham caused non-significant reduction in office SBP by 3.99 mmHg [(-8.10, 0.11); P = 0.06] and nighttime ambulatory SBP by 3.05 mmHg [(-6.86, 0.75), P = 0.12] and DBP by 1.03 mmHg [(-3.01, 0.96); P = 0.31]. There was no difference in the risk of hypertensive crisis/emergency [0.62; 0.24-1.60; P = 0.33] between the two strategies. Conclusions: Current meta-analysis shows that RD reduces ambulatory BP and office DBP in patients with hypertension. Future trials with longer follow-up should confirm these findings. (c) 2019 Elsevier Inc. All rights reserved.